Complications of spinal surgery for elderly patients with lumbar spinal stenosis in a super-aging country: An analysis of 8033 patients

doi:10.1016/j.jos.2016.08.014

Journal of Orthopaedic Science

Volume 22, Issue 1, January 2017, Pages 10-15

https://doi.org/10.1016/j.jos.2016.08.014 Get rights and content

Abstract

Background

The Japanese Society for Spine Surgery and Related Research (JSSR) performed a third study on complications in spinal surgery in 2011. The purpose was to present information about surgery and complications in a large amount of elderly patients aged 65 years with lumbar spinal stenosis (LSS) without coexisting spondylolisthesis, spondylolysis, or scoliosis, and to compare patients aged ≥80 years to those aged 65–79 years.

Methods

A recordable optical disc for data storage was sent by JSSR in January 2012 to 1105 surgeons certified by the JSSR in order to collect surgical data. Data were returned by the end of May 2012.

Results

Data were accumulated for 8033 patients aged 65 years. The incidence of surgical complications was 10.8%, and did not differ significantly between age groups. The incidence of general complications was 2.7%, and differed significantly between age groups (p < 0.005). The highest incidence of surgical complications was for dural tear (DT) (3.6%), followed by deep wound infection (DWI) (1.4%), neurological complications (1.3%), and epidural hematoma (1.3%). Spinal instrumentation was applied in 30.3%. Incidences of surgical complications in instrumented and noninstrumented surgery were 17.3% and 8.8%. In instrumented surgery, incidences of surgical and general complications were higher in the ≥80 year age group than in the 65–79 year age group. Logistic regression analyses showed patients with microendoscopic surgery at increased risk of DT. Patients with diabetes mellitus and instrumented surgery showed increased risks of DWI.

Conclusions

Incidences of surgical complications did not differ significantly between age groups. Attention should be paid to both surgical and general complications, particularly for postoperative mental disease in instrumented surgery for patients≥80 years old.

Introduction

The Japanese Society for Spine Surgery and Related Research (JSSR) forms part of the Japanese Orthopaedic Association (JOA) and comprises 3611 spine surgeons and researchers. The society performed three studies on the complications in spinal surgery in 1994, 2001, and 2011 [1], [2], [3], [4]. The results of the 2011 study as a whole [4] and another study comparing results among the 3 surveys [5] have been reported elsewhere, but detailed results regarding particular diseases have yet to be described.

Japan was the most aging society of the developed nations in 2010 [6]. As of the end of 2010, 23.1% of the Japanese population was aged >65 years, and 6.5% was aged >80 years.

Lumbar spinal stenosis (LSS) is a particularly common medical condition affecting the elderly, and the number of surgeries for this condition is increasing worldwide [7], [8]. Many surveys have identified this as the most popular spinal surgery [5], [9], [10]. Surgery for elderly patients with back and leg problems is aimed at maintaining activity in daily life as opposed to allowing them to become bedridden [11], but is also related to various risks threatening patient life.

Information regarding surgical treatment and complications performed on elderly patients with LSS in Japan may be useful for spine surgeons in other countries as their populations undergo similar aging. The purpose of this study was thus to present information about surgery and complications obtained from a large number of elderly patients with LSS from an aging society, and to compare patients aged ≥80 years to those aged 65–79 years (1620 and 6413 patients each).

Section snippets

Data collection

Data for this study were obtained from the study performed by the JSSR during the 1-year period from January 1 to December 31, 2011. The JSSR project team prepared two computerized questionnaires to capture both clinicopathological information (173 items) and surgical information (117 items). A recordable optical disc for data storage was sent by JSSR in January 2012 to all 1105 spine surgeons certified by the JSSR in order to collect surgical data. This data was returned by the end of May

Results

The certified surgeons were distributed among 750 institutions nationwide. Responses were obtained from 209 institutions (response rate, 28%). The total number of patients in the 2011 study was 31,380 [4], [5]. After excluding those cases that lacked principal information, data from 8033 patients aged ≥65 years were examined. These comprised 4302 men and 3731 women, with a mean age of 74.6 years (65–69 years: n = 1696; 70–79 years: n = 4717; 80–89 years: n = 1587; and ≥90 years: n = 33).

Discussion

There is no paper that analyzed so many patients aged ≥80 years with regard to surgical and general complications.

Nanjo et al. reported that the surgical outcome and the incidence of postoperation complications of decompression surgery for LSS without degenerative scoliosis of more than 10°, more than 3 mm spondylolisthesis or over 10° instability were similar between patients aged ≥80 and <80 years [12]. In this study, the incidence of surgical complications did not differ significantly

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgments

We are very grateful to doctors from the 209 participating institutions for their kind and generous cooperation with this study on spine surgery.

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In light of an aging global population, understanding adverse events (AEs) in surgeries for older adults is crucial for optimal outcomes and patient safety.
Our study compares surgical outcomes and AEs in patients aged 65–79 with those aged ≥80, focusing on clinical outcomes, morbidity and mortality rates, and age-related risk factors for AEs.
Our study, from January 2019 to December 2022, involved patients aged 65–79 and ≥ 80 undergoing spinal surgery. Each patient was evaluated for AEs post-discharge, defined as negative clinical outcomes within 30 days post-surgery. Patients were categorized based on primary spinal diagnoses: degenerative, oncological, traumatic, and infectious.
We enrolled 546 patients aged 65–79 and 184 octogenarians. Degenerative diseases were most common in both groups, with higher infection and tumor rates in the younger cohort. Octogenarians had a higher Charlson Comorbidity Index and longer ICU/hospital stays. Surgery-related AE rates were 8.1% for 65-79-year-olds and 15.8% for octogenarians, with mortality around 2% in both groups.
Our prospective analysis shows octogenarians are more susceptible to surgical AEs, linked to greater health complexities. Despite higher AEs in older patients, low mortality rates across both age groups highlight the safety of spinal surgery. Tracking AEs is crucial for patient communication and impacts healthcare accreditation and funding.
Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication
2023, Journal of Orthopaedic Science
Citation Excerpt :
Nine papers compared and discussed the surgical outcomes of patients aged >80 years (octagenarian and over) with patients aged <80 years as the controls [295–303]. The main surgical procedure was decompression alone, but two studies included fusion [296,301]. In the evaluation by JOA score and recovery rate, many studies reported improvement in the octagenarian and over as in the controls [295,299,300,303].
The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.
The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.
Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.
The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.
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The aim of this study is to utilize a national database to identify how age affects patient outcomes following anterior lumbar interbody fusion (ALIF). There are no established age guidelines for the geriatric population within the spine specialty, which makes patient selection challenging. Furthermore, there are conflicting studies for the risks of performing spine surgeries in the elderly.
A retrospective review of the Mariner Claims Database was conducted on patients who underwent a single level ALIF (CPT 22558) between 2010 and 2018. Patients were separated into three groups by age: 50–64, 65–74, and 75–84 and matched with respect to gender, smoking, and comorbidity burden. Multivariable logistic regression was used to determine the independent effect of outpatient surgery on the postoperative outcomes after adjusting for demographic factors and pertinent comorbidities. Statistical significance was set at p < 0.05.
The study identified 8459 matched patients (3350 50–64; 3350 65–74; and 1759 75–84). Compared with patients aged 50–64, patients aged 65–74 and 75–84 had significantly increased risks of pneumonia (65–74: OR 1.53, 95% CI 1.06–2.24, p = 0.025; 75–84: OR 1.62, 95% CI 1.07–2.42, p = 0.022), sepsis (65–74: OR 2.20, 95% CI 1.36–3.76, p = 0.002; 75–84: OR 2.42, 95% CI 1.43–4.13, p = 0.001), and major complications (65–74: OR 1.35, 95% CI 1.05–1.74, p = 0.021; 75–84: OR 1.48, 95% CI 1.11–1.95, p = 0.006) (Table 2). There were no significant differences between patients aged 65–74 and 75–84 for risks of postoperative pneumonia, sepsis, and major complications (p > 0.05). There were no differences between any groups in terms of long-term outcomes such as pseudoarthrosis, implant related complications, or reoperation (p > 0.05) (Table 3).
The study showed that those older than 65 had a significant increase in risk of pneumonia, sepsis, and major complications following ALIF. In the two cohorts above the age of 65 (65–74 and 75–84) there was no significant differences in postoperative outcomes.
3
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The indications and contraindications to the endoscopic transforaminal approach for lumbar spinal stenosis are not well defined.
We performed a Kaplan-Meier durability survival analysis of patients with the following types of spinal stenosis: type I, central canal; type II, lateral recess; type III, foraminal; and type IV, extraforaminal. The 304 patients comprised 140 men and 164 women, with an average age of 51.68 ± 15.78 years. The average follow-up was 45.3 years (range, 18–90 years). The primary clinical outcome measures were the Oswestry Disability Index, visual analog scale, and the modified Macnab criteria.
Of 304 study patients, 70 had type I (23.0%) stenosis, 42 type II (13.7%), 151 type III (49.7%), and 41 type IV (13.5%). Excellent outcomes were obtained in 114 patients (37.5%), good in 152 (50.0%), fair in 33 (10.9%), and poor in 5 (1.6%). Kaplan-Meier durability analysis of the clinical treatment benefit with the endoscopic transforaminal decompression surgery showed statistically significance differences (P < 0.0001) on log-rank (Mantel-Cox) χ² testing between the estimated median (50% percentile) survival times of type I (28 months), type II (53 months), type III (32 months), and type IV (66 months).
We recommend stratifying patients based on the underlying compressive disease and the skill level of the endoscopic spine surgeon to decide preoperatively whether more difficult central or complex foraminal stenotic lesions should be considered for alternative endoscopic approaches.
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Lumbar degenerative disease remains one of the most common musculoskeletal disorders worldwide, with high prevalence among the elderly. Lumbar surgery remains an effective management option for this population with comparable functional outcomes to younger populations. Despite the associated high comorbidity burden and increased risk of medical complications, advanced age alone is not a contraindication for more invasive techniques, like instrumented fusion. Several biologics have been utilized to aid physiological fusion including parathyroid hormone, bisphosphonates, bone morphogenic protein, and more controversially stem cell based therapies, all of which have shown promising results in their ability to enhance bony union
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Citation Excerpt :
To the best of our knowledge, this is the first study to demonstrate an association between preoperative NT-proBNP levels and adverse perioperative events in patients undergoing SS. As surgery remains the cornerstone of curative therapy, the number of older patients admitted for SS is increasing rapidly.8,9 Elective SS is commonly performed and is a major component of health care costs in Turkey.
The utility of preoperative biomarkers for assessing perioperative complications in patients undergoing spine surgery (SS) is unclear, and no study has assessed the ability of preoperative natriuretic peptides to predict adverse events following SS. This study aimed to evaluate the prognostic importance of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients undergoing SS.
We prospectively followed 154 consecutive adult patients ≥50 years old hospitalized for elective SS. The outcomes of interest were length of stay in hospital and perioperative medical complications during hospitalization, defined as pneumonia, deep or organ space surgical site infection, bacteremia, prolonged mechanical ventilation >48 hours, unplanned reintubation, acute renal failure, sepsis or septic shock, venous thromboembolism (deep vein thrombosis or pulmonary embolism), cardiac arrest, stroke, myocardial infarction, return to operating room, and in-hospital mortality.
In 21 (13.6%) patients, 32 episodes of medical adverse events occurred. Older patients and patients with more comorbid conditions, such as heart failure, diabetes, cerebrovascular disease, coronary artery disease, and chronic obstructive pulmonary disease, tended to have a higher rate of adverse events. Patients with adverse events had higher NT-proBNP and troponin levels on admission compared with patients without adverse events. Multivariate analysis showed that NT-proBNP >242 pg/ml (odds ratio 2.374; 95% confidence interval, 1.000–2.958; P = 0.001) and presence of diabetes (odds ratio 2.16; 95% confidence interval, 1.86–7.89; P = 0.008) were significant and independent predictors of perioperative adverse events.
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Original ArticleComplications of spinal surgery for elderly patients with lumbar spinal stenosis in a super-aging country: An analysis of 8033 patients

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Data collection

Results

Discussion

Conflict of interest

Acknowledgments

J Orthop Sci

J Orthop Sci

J Orthop Sci

Nationwide survey for spine surgery

J Jpn Spine Reseach Soc A Comm Rep

Complication of the spine surgery: results of the complication survey of the Japan Spine Research Society

J Jpn Orthop Assoc

Nationwide survey for spine surgery in Japan

J Spine Res

The international spine registry SPINE TANGO: status quo and first results

Eur Spine J

Surgery versus conservative treatment for symptomatic lumbar spinal stenosis. A systematic review of randomized controlled trials

Spine

Low back pain hospitalization: recent United States trends and regional variations

Spine

Operative treatment for lumbar canal stenosis in the elderly (more than 80 years old)

Cent Jpn J Orthop Traumat

Clinical features and surgical outcomes of lumbar spinal stenosis in patients aged 80 years or older: a multi-center retrospective study

Arch Orthop Trauma Surg

Long-term outcome of laminectomy for spinal stenosis in octogenarians

Spine

Long-term outcome of decompressive surgery for lumbar spinal stenosis in octogenarians

Eur Spine J

Original Article
Complications of spinal surgery for elderly patients with lumbar spinal stenosis in a super-aging country: An analysis of 8033 patients